F0656

D

Incomplete and Non-Specific Care Plans for Fall Risk and Independent Smokers

Waldorf, Maryland Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to develop and implement comprehensive, individualized care plans for multiple residents. For one resident reviewed for change in condition, the care plan included a focus of risk for falls related to CVA and impaired mobility, with a goal of no falls with injury for 90 days. However, specific interventions were left incomplete: the intervention for fall mats did not indicate the number or sides to be used, and the intervention directing staff to place personal items within reach did not specify which personal items. During review, the DON acknowledged that this care plan was not sufficiently personalized or specific to the resident’s needs.

For two residents reviewed for accidents who were identified as independent smokers, the facility failed to develop complete person-centered care plans that included specific interventions. Both residents had smoking evaluations indicating they were independent smokers, and each had a care plan focus stating that the resident may smoke independently per smoking assessment, with goals that the resident would smoke safely by the next review or for 90 days. Despite this, the care plans did not include any detailed interventions describing the specific care and services to be implemented to meet the stated goals for safe smoking. This lack of defined interventions for independent smokers was confirmed during record review and staff interview.